Cleaning in Healthcare Facilities - Virox Technologies Inc.

H E A L T H

C A R E

R E S E A R C H

C O L L A B O R A T I V E

Cleaning in Healthcare Facilities Reducing human health effects and environmental impacts APRIL 2009

AUTHORS:

Pia Markkanen, ScD, Margaret Quinn ScD, CIH, Catherine Galligan, MSc, Anila Bello, ScD

Health Care Without Harm has initiated a research collaborative coordinated by faculty of the University of Illinois at Chicago School of Public Health, with support from the Pioneer Portfolio of the Robert Wood Johnson Foundation, aimed at stimulating collaborative research around health and safety improvements in health care. This collaborative is designed to increase the evidence base concerning the human health and environmental impacts of materials, products and practices within health care. In partnership with the Global Health and Safety Initiative (GHSI), the Research Collaborative is engaged in research directed at the intersection of environmental, patient, and worker safety issues related to building and operating health care institutions. This paper is part of a series in which the Collaborative will provide research and analysis of the health and environmental impacts of select groups of this new generation of materials and facilitate sharing of experiences on installation, maintenance and performance.

TA B L E O F C O N T E N T S Acknowledgements.........................................................................................................................................2 Executive Summary........................................................................................................................................3 I.

Introduction..........................................................................................................................................6

II.

Purpose and development of this document ...........................................................................................7

III. Background...........................................................................................................................................8 Definitions for cleaning and disinfection..............................................................................................................8 Cleaning and potential harms to health and the environment ...........................................................................8 Significance of cleaning in the healthcare sector..................................................................................................9 The cleaning system............................................................................................................................................10 IV.

Health and environmental hazards: scientific and professional evidence ..............................................11 Human health effects...........................................................................................................................................11 Exposure assessment efforts..................................................................................................................................12 Environmental impacts........................................................................................................................................13

V.

Healthier and more environmentally friendly cleaning for healthcare....................................................14 What is green cleaning?.......................................................................................................................................14 Benefits of green cleaning and examples of efforts..............................................................................................14 Cleaning, disinfecting, and antimicrobials products...........................................................................................15

VI. Systems approach ...............................................................................................................................17 SHP experience with a systems approach to changing practices in hospitals....................................................18 Practice Greenhealth approach...........................................................................................................................20 Management and the team..................................................................................................................................20 VII. Green movements in the healthcare sector...........................................................................................21 LEED for Healthcare............................................................................................................................................21 Green cleaner certification programs..................................................................................................................21 VIII. Moving upstream towards non-chemical alternatives.............................................................................23 IX. Conclusions and recommendations.......................................................................................................25 List of references..........................................................................................................................................27 Appendix A: Examples of hazardous ingredients in conventional cleaning products .......................................31 Appendix B: Information on green cleaning efforts in healthcare facilities......................................................34 Appendix C: Selected sources for choosing industrial green cleaning products ...............................................36

Acknowledgements This paper has been jointly commissioned by Health Care Without Harm and the Global Health and Safety Initiative. It has been developed by the research team at the Sustainable Hospitals Program (SHP), a program of the Lowell Center for Sustainable Production (LCSP) at the University of Massachusetts Lowell. The authors gratefully acknowledge the following persons in the development and review of this document: • Cathy Crumbley, Program Director, the Lowell Center for Sustainable Production; • Judene Bartley (MSc, MPH, CIC) Vice President of the Epidemiology Consulting Services, Inc. This paper was generously funded from the Pioneer Portfolio of the Robert Wood Johnson Foundation. Design & Layout by Kieran Daly & Parisa Damian of Winking Fish.

The Sustainable Hospitals Program

The Sustainable Hospitals Program (SHP) was initiated at the University of Massachusetts Lowell in 1998 to provide science-based technical guidance to the healthcare industry for selecting products and practices that promote occupational and environmental health and safety. Based within the Lowell Center for Sustainable Production (LCSP), the SHP aims to fully integrate occupational and environmental health and safety into comprehensive solutions for more sustainable healthcare. The SHP and LCSP have a research program to promote safer and more environmentally sound cleaning materials and practices. This work has the following components:

1. Conducting exposure assessments. Identifying

what workers, patients and other building occupants are exposed to is the first step in improving cleaning. The SHP has an occupational/environmental hygiene laboratory and field equipment and has developed the technical expertise to measure exposures from cleaning.

2. Characterizing the health effects of cleaning products. Epidemiologists on our team have experience conducting field studies as well as in con-

ducting systematic reviews of the health literature. The LCSP collaborated with Health Care Without Harm to write “Risks to Asthma Posed by Indoor Health Care Environments: A Guide to Identifying and Reducing Problematic Exposures”.1

3. Assessing the effectiveness of new cleaning products. The Surface Solutions Laboratory (SSL)

of the LCSP-UMass Lowell sister organization, The Toxic Use Reduction Institute (TURI), conducts efficacy testing on cleaning products and promotes the use of green cleaners.2-4 TURI offers an interactive, free-of-charge online database on surface cleaning5— called CleanerSolutions—to help manufacturers find safer cleaning alternatives that perform as well as the products based on hazardous chemicals. It also provides online information including “Ten Ways to Find Safer and Greener Cleaners”.6 The TURI SSL is certified by Green Seal—the US eco-labeling organization—to test the efficacy of green products.

4. Conducting field studies to assist healthcare facilities in implementing alternative cleaning products and practices. Over the past decade,

the SHP has used participatory processes for implementing healthier and more sustainable workplace programs through the Pollution Prevention-Occupational Safety and Health alternatives assessment strategy (P2OSH).7

5. Translating sound environmental practices into social policy and regulations. We work with healthcare providers and insurers to improve the provision of environmental remediation for asthma triggers in the home.8-10 Another example of the translation of research to practice is a project with a Brazilian women’s organization to educate Brazilian domestic cleaners about the hazards of household cleaners and help them to replace these with less toxic cleaners made from safer ingredients.11 Lowell Center of Sustainable Production University of Massachusetts Lowell One University Avenue • Lowell, MA 01854 978-934-2980 www.sustainableproduction.org

EXECUTIVE SUMMARY Cleaning of healthcare facilities is performed for medical and cultural reasons. Maintaining an environment with a low pathogenic burden is essential for avoiding complications during the care and recuperation of patients. A healthy, safe, and aesthetically pleasing space with clean surfaces is comforting to patients and their families by giving an impression of good quality care without additional health hazards. While cleaning is important in all economic sectors, it serves the healthcare industry the dual functions of: (i) surface cleanliness, and (ii) infection prevention and control. As such, healthcare settings require intensive and frequent cleaning with a wide range of products. This document summarizes the main health and environmental impacts related to conventional surface cleaning, describes a systems approach for designing and implementing healthier and environmentally friendlier cleaning strategies for the healthcare sector, and indicates areas where future research and policy initiatives are needed.

Cleaning for infection prevention and control

Improvements in the health and environmental impacts of cleaning must be considered along with concerns for infection prevention and control. Healthcare settings are engaged in a battle against healthcareassociated infections (HAIs).12 The importance of infection prevention and control is increasing due to rapidly developing strains of multi-drug resistant organisms (MDROs) that can result in serious illness and even death in workers and patients. In 2002, US hospitals reported about 1.7 million HAIs, associated with almost 99,000 deaths.13 The proportion of S. aureus bloodstream infections due to MRSA increased significantly from 27% in the period of 1990-1994 to 54% during 2000-2004 (P > .001).13 Studies have estimated that antimicrobial drug-resistant infections

have increased direct costs to society by 30%-100%.14 The excess cost of a single MRSA infection compared with a methicillin-sensitive S. aureus infection was estimated to range from $3,000 to $25,000.14 This suggests that MRSA costs the healthcare system (patients and healthcare facilities) an estimated additional $830 million to $9.7 billion in 2005—excluding the indirect costs related to psychological suffering of patients and their family members as well as lost work time spent in the hospital.14

Potential health and environmental impacts of cleaning chemicals

Many hospitals have increased the use of cleaning and disinfecting products to address HAIs as well as other infection prevention and control concerns. However, conventional cleaning products and disinfectants bring a host of other health hazards despite their capacity to fight against MDROs. This document provides a literature review of cleaning products and their adverse effects on human health and the environment. Conventional cleaning products are complex mixtures of chemical ingredients. Many of these ingredients are known or suspected to be associated with asthma and

Cleaning in healthcare facilities: Reducing human health effects and environmental impacts

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other respiratory disorders. Some others are associated with dermatitis, endocrine and neurologic effects, and cancer. However, many ingredients have not been tested and so their effects are still unknown. Potentially harmful exposures from cleaning are a function of multiple factors, including: (i) the chemical characteristics of the cleaning product, (ii) the physical characteristics (aerosols vs. liquids for example), (iii) the characteristics of cleaning tasks (spraying vs. mopping), and (iv) the characteristics of the built environment (ventilation, room size).15 There is evidence that some cleaning product ingredients harm the environment. They may bioaccumulate in plants and animals, damage aquatic ecosystems, and pollute indoor air, outdoor air, and drinking water supplies.16

Greener cleaning

Concerns about adverse human and environmental health effects of conventional cleaning products have led to the development of “green” cleaners. Some green cleaners may reduce human health and environmental effects as well as reduce costs. However, little is known about whether green cleaning programs meet or compromise infection control and prevention goals. Interestingly, there is no widely accepted definition of “green” or “green cleaning”. US Executive Order 13101 defines “environmentally preferable” as “products or services that have a lesser or reduced effect on human health and the environment when compared with competing products or services that serve the same purpose”.17 However, the American Society for Healthcare Environmental Services (ASHES) recommends that the “green cleaning” definition be expanded to address the efficacy of infection control and prevention “towards effective products with the fewest adverse effects on human health and the environment.”18 There are several widely recognized standards for green cleaners, including: Green Seal, the Canadian Environmental Choice program, the US EPA’s design for the Environment Formulation Program, Cradle-to-Cradle, the Nordic Swan, European Union’s EcoLabel, and Blue Angel in Germany.19 The healthcare sector as a whole is working to develop and implement sustainable and green initiatives, including green cleaning programs. One of the most visible and influential initiatives is the impending 2009 launch of the new Leadership in Energy and Environmental Design (LEED) certification program tailored for the healthcare indus-

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try.20 One of the issues it addresses is increased sensitivity to chemicals and pollutants, which will increase interest in implementing green cleaning programs in healthcare facilities.

Systems approach for greening the cleaning

Frequently, green cleaners have been designed as “dropin” substitutes for conventional cleaning products—a product with a new formulation of chemical ingredients that can simply replace the conventional product. This method typically fails to take into account the “three safeties” described by the Global Health and Safety Initiative—patient, worker, and environmental safety—and may adequately address only one aspect. Greening the cleaning process is not just about transitioning to more benign chemicals but also about broadly examining the purpose that cleaning serves and systematically considering alternative, and sometimes very different, strategies for minimizing unintended consequences while achieving the desired outcome. Therefore, the system approach to cleaning is crucial. It considers a range of options spanning the entire cleaning service as well as the procurement, use, and disposal of cleaning products, materials, and equipment. Furthermore, it takes into account different levels of the built environment (e.g., building materials), new technologies (e.g., UV light for disinfection), new cleaning chemicals (e.g., greener products), and the social-economic influences on cleaning in healthcare (e.g, Centers of Medicare/Medicaid reimbursement policies). The implementation of a change in the cleaning system should involve all parties affected and manages the change program comprehensively in a step-by-step fashion.

Moving toward non-chemical alternatives

Successful green cleaning programs move upstream in the cleaning process towards non-chemical or less toxic alternatives by identifying new technologies, building materials, work practices (e.g., how cleaning products are used and disposed, how cleaning tasks are performed, or the physical conditions in which cleaning is performed) as a means of strengthening infection prevention and control goals. For example, microfiber mops and cloths have been shown as effective and safe alternatives to traditional rag mops, decreasing the use


of harsh chemical cleaners, and potentially reducing back pain and injury from water buckets and mops.7, 21-24 An entire building and its operational design needs to be considered for environmentally friendlier cleaning strategies. This may range from choosing surface materials that are easy to maintain and clean with the greenest product available to minimizing patient and worker exposure to cleaning and disinfecting products.

are performed), there is limited information about how cleaning tasks generate respiratory and dermal exposures. The following research projects and educational initiatives could address these knowledge gaps:

Recommendations and closing the knowledge gap

• Qualitative studies to provide in-depth information on the nature, effectiveness, and impacts of environmentally friendly cleaning programs in selected hospitals.

The authors recommend the following future action areas: • Develop a systematic definition of green cleaning to address the importance of: (i) human health and environmental protection, as well as (ii) infection control and prevention efficacy. • Develop a universal standard to test cleaning and disinfection efficacy in different laboratories and workplaces. • Examine cleaning in healthcare from a systems perspective to effectively address “three safeties”— patient, worker, and environmental safety. While green cleaning products offer promise for human health and the environment, the literature review for this paper found few comprehensive scientific studies examining important aspects of green cleaning. Although infection prevention and control are fundamental reasons for cleaning in hospitals, there were few studies examining the efficacy of green cleaning products for this purpose. No scientific studies were found on the health impacts of green cleaners. While it has been shown that respiratory and dermal exposures result from a combination of factors (i.e., products used, ambient conditions, physical space, and the way tasks

• Collaborative studies with infection preventionists, microbiologists, and health scientists to evaluate how effectively green cleaners meet infection control and prevention goals.

• Human health studies on green cleaning products focusing on asthma and other health effects. • A study to assess worker exposures with green cleaners in typical work scenarios. • A freely accessible, clearinghouse on green cleaning—i.e., an online central repository of information about green cleaning for identifying and sharing best practices. • Factsheets for frontline workers to provide readerfriendly how-to-guidance on various green cleaning products and practices. • Case studies to serve as practical overviews of implementing new cleaning products and practices.


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I.

INTRODUCTION

Cleaning is a common activity performed to maintain a healthy, safe, and aesthetically pleasing environment. Various cleaning products have become ubiquitous parts of our everyday lives. There is increasing evidence that cleaning is related to asthma and other respiratory illnesses among those who perform cleaning tasks or spend time in recently cleaned indoor environments. While cleaning is common in nearly all industry sectors and in homes, it is particularly important in healthcare which requires intensive and frequent cleaning and uses a wide range of cleaning and disinfecting products. Cleaning in healthcare serves the dual functions of providing surface cleanliness and infection prevention and control. Both the importance and complexity of infection prevention and control are increasing due to rapidly developing strains of multidrug-resistant organisms that can result in serious worker and patient illness and even death. The recent decision25 of the Center for Medicare and Medicaid Services (CMS) that it will no longer provide additional reimbursement to hospitals for specific hospital-acquired infections may add a strong economic incentive for infection prevention and control measures, including the use of more cleaners and disinfectants. More importantly the media attention to certain antibioticresistant organisms such as Methicillin-resistant Staphylococcus aureus (MRSA) or infectious agents that form spores (e.g., Clostrium difficile) has intensified interest in cleaning and disinfection in healthcare facilities.26

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Cleaning products are complex mixtures of chemical ingredients. Toxicologic analyses of cleaning products show that many contain chemicals that are known or suspected triggers of asthma and other respiratory problems. Some of these ingredients are also associated with dermatitis, endocrine and neurologic effects, and cancer. However, many ingredients have not been tested and so their effects are still unknown. Several population-based studies confirm that healthcare workers who are exposed to cleaning products have high rates of asthma and other respiratory symptoms, including illness severe enough to result in lost time from work. However, very few of these studies provide information about which specific ingredients are related to the health effects and which cleaning tasks are most hazardous. In addition to human health effects, there is evidence that some cleaning product ingredients harm the environment, damaging aquatic ecosystems and causing air and water pollution. Concern for the environmental effects of cleaning products led to the development of new products, called “green cleaners”. However, these new products neither have consistent criteria for their environmental benefits, nor do they always consider the human health effects. As a result some green cleaners can still cause health problems. Changes to reduce the harmful effects of cleaning must ensure effective infection prevention and control as well as being more healthy, safe, and environmentally sound. To develop new approaches that account for health, environment as well as infection prevention and control, it would be useful to have a broad overview of the functions of cleaning and the work environment systems in which it is performed. With this information, a full range of options for effective change can be identified and evaluated.


II.

PURPOSE AND DEVELOPMENT OF THIS DOCUMENT

The purpose of this document is to summarize the main health and environmental impacts related to conventional surface cleaning and define a systems approach for designing and implementing healthier, more environmentally sound cleaning strategies in the healthcare sector. It is structured in three major sections: (i) Scientific and professional evidence on health and environmental hazards related to surface cleaning, including disinfection*; (ii) Green cleaning in healthcare and a systems approach to implement it; and (iii) Conclusions and recommendations to identify knowledge gaps and recommendations for future action. This document is primarily written for hospital decision makers including operations and facilities managers, infection preventionists, and occupational and environmental hygienists who can use the information to improve current cleaning practices or take steps to advance healthier, more environmentally sound cleaning in their facilities. The document will also serve as a useful tool for other stakeholders, including public health practitioners, clinicians, healthcare environmental health and safety advocates, researchers, insurers, manufacturers, and cleaning service providers.

strategy as well as Practice Greenhealth’s** “Ten Step Guide to Green Cleaning Implementation.”27 This document also draws examples from valuable tools and guidelines developed for sustainable healthcare including INFORM, INC’s Cleaning for Health report,28 Green Guide for Health Care,29 Sustainable Healthcare Architecture,30 Minnesota Technical Assistance Program’s Intern Project (MnTap),31 US EPA sources,21, 32, 33 and Practice Greenhealth website on green cleaning.34 The selected resources are used as examples and there is no implication that these are the only resources or the most appropriate for a particular application.

The SHP reviewed current studies, literature, policies, advocacy materials, and Internet-based tools. The literature cited in this document includes international and US-based health studies related to cleaning products, professional journals on infection prevention and control as well as reports and magazine articles on green cleaning, studies and reports developed at the University of Massachusetts Lowell (UMASS Lowell), and green cleaning advocacy materials. As examples of a systems approach in implementing green cleaning practices within a specific group or department of a healthcare facility, we present both the SHP’s Pollution Prevention-Occupational Safety Health (P2OSH)

* This document does not address sterilization of medical instruments/ equipment.

** Practice Greenhealth is a membership and networking organization for the healthcare community institutions (e.g., hospitals, healthcare systems, businesses, and other) committed to sustainable and ecofriendly practices.


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III.

BACKGROUND

Definitions for cleaning and disinfection Cleaning products are designed to remove surface contaminants like soil particles and grease. Disinfecting products are meant to destroy microorganisms. Both cleaning and disinfecting products are often a mixture of many chemical ingredients. The Centers for Disease Control and Prevention (CDC) uses these definitions for cleaning, disinfection, and sterilization in healthcare35,36: • Cleaning is the removal of visible soil (e.g., organic and inorganic material) from objects and surfaces and normally is accomplished manually or mechanically using water with detergents or enzymatic products.35 or • Cleaning is a form of decontamination that renders the environmental surface safe to handle or use by removing organic matter, salts, and visible soils, all of which interfere with microbial inactivation.36 • Disinfection describes a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects.35 In addition, the CDC defines sterilization as a process that destroys or eliminates all forms of microbial life, including bacterial spores.35

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Antimicrobial products are registered as pesticides under the US Environmental Protection Agency (EPA) which uses this definition for antimicrobial pesticides37: • Antimicrobial pesticides are substances or mixtures of substances used to destroy or suppress the growth of harmful microorganisms whether bacteria, viruses, or fungi on inanimate objects and surfaces. Antimicrobial pesticides have two major uses: (1) disinfect, sanitize, reduce, or mitigate growth or development of microbiological organisms; (2) protect inanimate objects (e.g., floors and walls), industrial processes or systems, surfaces, water, or other chemical substances from contamination, fouling, or deterioration caused by bacteria, viruses, fungi, protozoa, algae, or slime.37

Cleaning and potential harms to health and the environment While cleaning and disinfecting have essential benefits for combating infections, there is evidence of an association of conventional cleaning products with adverse health effects among cleaning staff and building occupants. Epidemiologic studies (see Section IV), carried out mostly in Europe, show that cleaning products are associated with respiratory irritation and asthma. In addition to potential harms to health, environmental risks are evident: many cleaning chemicals released into the environment biodegrade slowly or incompletely, posing a risk of water supply contamination and/or impact on wildlife. Nearly all used cleaning products and wastewater are disposed into municipal sewers. So far, efforts to replace toxic cleaning products with green cleaners have mostly focused on environmental impacts and not accounted


for worker and patient health impacts, nor have they adequately addressed infection prevention and control functions. This has led to green cleaners that are less bio-persistent in the environment, but may still contain asthmagens or other unhealthy ingredients to the respiratory system. There are significant driving forces in the US for implementation of green cleaning. For example, Colorado, Connecticut, New Jersey, New York, and Wisconsin have issued Executive Orders for greener cleaning practices.38 Even more important may be the widespread acceptance of Leadership in Energy and Environmental Design (LEED), the US Green Building Council’s (USGBC) third-party certification program and benchmark for the design, construction and operation of high performance green buildings. LEED promotes a whole-building approach to sustainability by recognizing performance in five key areas of human and environmental health: sustainable site development, water savings, energy efficiency, materials selection and indoor environmental quality. Cleaning strategies are one element of LEED green performance.39 In addition to voluntary adoption of the LEED certification program, the LEED criteria have been mandated by many federal, state and municipal governments (e.g., through legislation, executive orders, resolutions, ordinances, incentives, and the like) for buildings receiving their funding. As of January 1, 2009, this was evident in at least 44 US states, including 172 localities (112 cities, 32 counties, and 28 towns), 31 state governments, 12 federal agencies or departments, 15 public school jurisdictions and 39 institutions of higher education.40

Significance of cleaning in the healthcare sector Cleaning holds special importance for hospitals and other healthcare facilities. The healthcare industry represents a significant population for health studies on cleaners because of the intensive and frequent cleaning with a wide range of cleaning and disinfecting products. While the aesthetic benefits of cleaning are necessary for attracting and retaining patients, cleaning and disinfection play an essential role in healthcare settings by

preventing healthcare-associated infections (HAIs)*. In 2002, United States hospitals reported about 1.7 million HAIs which caused almost 99,000 deaths.13 The fight against multidrug-resistant organisms (MDROs) is essential in HAI prevention efforts.13 Specifically, the proportion of S.aureus bloodstream infections due to MRSA increased significantly overall, from 27% in the period 1990–1994 to 54% in the period 2000–2004 (P > .001).13 Studies have estimated that antimicrobial drug-resistant infections increase death, illness, and direct costs by 30%–100%.14 Estimates of the excess cost of an infection with MRSA compared with an infection with methicillin-sensitive S. aureus range from ≈$3,000 to $35,000.14 This suggests that MRSA cost the healthcare system (patients and hospitals) an extra $830 million–$9.7 billion in 2005, even without taking into account indirect costs related to patient pain, illness, and time spent in the hospital.14 Cleaning has been highlighted as a serious responsibility and a critical factor in the battle against HAIs.12 HAI prevention has led to an international debate on the extent to which surface disinfection is necessary for patient care.41-50 Besides educational interventions, researchers have recommended evaluating the thoroughness of cleaning and disinfection.26,51-54. Carling and colleagues developed a pioneering method for measuring removal of microbes: an environmentally stable, non-toxic targeting solution with a chemical marker that fluoresces brightly in ultraviolet or “black” light.51,54 In 2008, Carling et al published the results of a study which showed the effectiveness of cleaning and disinfection in randomly selected patient rooms and bathroom areas of 23 acute care hospitals.26,54 They found that cleaning thoroughness varied widely. For example, toilet handholds, bedpan cleaners, light switches, doorknobs, patient phones, nurse call devices, and bedside rails were poorly cleaned.26,54 Providing these findings to healthcare workers led to measurable cleaning improvements. As the use of cleaning and disinfecting agents is increasing due to infection prevention and control efforts, there is movement towards green cleaners or products that have fewer potential harms to health. A LEED certification program tailored for the healthcare industry, LEED for Healthcare (Green Guide for * Also referred in the literature as “hospital-acquired infections” or “nosocomial infections”.


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Improving cleaning is not just about transitioning to more benign chemicals but also about broadly examining the purpose that cleaning serves and systematically considering alternative, and sometimes very different, strategies for minimizing unintended consequences while achieving the desired outcome.

The cleaning system

Health Care), is expected to be launched in 2009.20,29,30 One of the issues it addresses is sensitivity to chemicals and pollutants, which will increase interest in implementing green cleaning programs in healthcare facilities.29 Other studies and groups are also driving forces for change; Lehman and INFORM, Inc. called for redefining “clean” and noted that one of the fundamental environmental protection guidelines is to clean for health first and appearance second—sparkling “whiter than white” appearance is not necessarily the healthiest and the smell of truly healthy cleaning is no smell at all.28,55 Hence, it is not surprising that healthcare is one of the top five fastest-growing segments in the environmentally friendly cleaning industry.18 There are many challenges associated with improving cleaning practices in hospitals. Healthcare staff and administrators often react skeptically to change, fearing that new cleaning products and practices might detract from rigorous infection prevention and control practices and thus lead to increased cases of HAIs. Another challenge is that many “improved” products, including green cleaners, are usually designed as “dropin” substitutes for conventional cleaning products—a product with a new formulation of chemical ingredients that can simply replace the conventional product. This method typically fails to take into account the “three safeties” described by the Global Health and Safety Initiative—patient, worker, and environmental safety—and may adequately address only one aspect.56

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In addition to the chemical characteristics of the product, the work of Bello et al15 shows that potentially harmful exposures from cleaning are also a function of (i) the physical characteristics of the cleaning product (aerosols vs liquids for example), (ii) characteristics of cleaning tasks (spraying vs. mopping), and (iii) characteristics of the built environment (ventilation, room size). Other studies demonstrate that building design itself can enhance or hinder effective cleaning.30 All of these together form the system of cleaning along with the network of people who perform cleaning, purchase cleaning products and materials, and dispose of them. The system approach considers a range of options spanning all aspects of cleaning operations as well as the procurement, use, and disposal of cleaning products, materials, and equipment. It also considers different levels of the built environment (e.g., building materials), new technologies (e.g., UV light for disinfection), new cleaning chemicals, and the social-economic influences for cleaning in healthcare (e.g., as noted earlier the Center for Medicare and Medicaid Services [CMS] reimbursement policies for HAIs may increase cleaning in healthcare). The implementation of a change in the cleaning system involves all parties affected and manages the change program comprehensively in a step-bystep fashion.


IV.

H E A LT H A N D E N V I R O N M E N TA L HAZARDS: SCIENTIFIC AND PROFESSIONAL EVIDENCE

Human health effects Nearly all cleaning products are complex mixtures of chemicals. The material safety data sheets (MSDSs) for many products indicate that they contain hazardous ingredients with the potential to cause adverse health effects, including serious respiratory ailments, eye and skin irritation, central nervous system disorders, reproductive disorders, blood disorders, and even cancer. However, MSDSs are notorious for being incomplete and are only required to report ingredients that constitute at least 1% by volume of the product. This means that some hazardous ingredients are not reported on the MSDS and workplaces cannot rely on them for complete toxicologic information. In addition, it has been suggested that chemical mixtures may magnify hazardous characteristics of some individual ingredients.57,58 Appendix A lists the most common chemical compounds in cleaning products and their health effects. • Chemical types. A toxicologically significant chemical group used in cleaning chemicals is volatile organic compounds (VOCs), which evaporate readily at ambient conditions (i.e., they have a low boiling point and high vapor pressure).59 VOCs belong to different families of organic chemicals defined by their chemical formula—each of which possesses common properties, although there may be major toxicological differences from family to family.60 Many VOCs are associated with poor indoor air quality59,61 and are known to participate in photochemical reactions both indoors and outdoors, generating harmful ozone (smog) in the environment.62 Glycol ethers are another common chemical group in cleaning products. Although glycol ethers have higher boiling points than many other organic solvents, they are hazardous compounds.63-68 Starek and colleagues found that ethylene glycol alkyl ethers have both acute and chronic health effects and target the central nervous system, blood and bloodforming organs, and reproductive system.67,68 Among ethylene glycol alkyl ethers, 2-butoxyethanol has

gained interest in health studies69 because of its toxic properties and frequent use in cleaners. Quaternary ammonium compounds—used as disinfectants—are strong skin and eye irritants15 and associated with occupational asthma.15,61,70,71 Phenols, such as orthobenzyl-para-chlorophenol (OBPC) and othro-phenyl phenol (OPP), are disinfectants less commonly used in hospitals, with more shift to quaternary ammonium compounds for general cleaning and are severe eye irritants as well as corrosive and sensitizing to the skin at high concentrations.72 Ethanolamines— applied as surfactants in cleaning products—have also been associated with occupational asthma and at certain threshold concentrations, the vapors can irritate the nose, throat, and lungs causing coughing, wheezing and shortness of breath.73 Among inorganic chemicals, chlorine compounds74 (in particular sodium hypoclorite [bleach]74-76) and ammonia74 are common ingredients used in disinfectants. • Acute injuries from chemical exposures also occur. The 1995 - 1997 workers’ compensation data for the State of Washington revealed that about 290 janitors per year who were working in various industries submitted claims for lost time injuries from chemical exposures—these injuries comprised 43% eye irritations or burns, 36% skin irritations or burns, and 12% inhalation of chemical fumes.33 In 1989, two janitors in Chicago died after inhaling toxic fumes while cleaning a floor.77 It was found that the floor cleaning solution contained methylene chloride.77 In their study of female domestic cleaners in Spain, Medina-Ramon and colleagues reported that more than half of the study population had at some time accidentally inhaled a large amount of cleaning product vapors, gas, or fumes when using cleaning products. About two thirds of these accidents were related to inappropriate mixing of two or more cleaning products, mostly containing bleach. Accidents related to a single product involved predominantly hydrochloric acid or ammonia.74


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Epidemiologic and professional reports provide strong evidence that exposure to cleaning products is associated with asthma and other respiratory symptoms.1,59,61,70,71,73-76,78-92 Delclos and colleagues (2007) found an approximately twofold increased likelihood of work-related asthma among US health care workers for tasks involving instrument cleaning and disinfection, use of general cleaning products used on indoor building surfaces, use of powdered latex gloves, or the administration of aerosolized medications.81 Pechter et al. investigated four US state-based surveillance systems for occupational asthma data during 19931997.87 Despite demographic and employment pattern variations across four states, healthcare emerged as the first or second most frequently reported industry among all occupational asthma cases, based on physician reports. Cleaning products, both cleaners and disinfectants, were the predominant exposure source, followed by latex, glutaraldehyde and formaldehyde, and indoor-air pollutants.87 Rosenman et al. studied the same four surveillance systems to characterize individuals with work-related asthma associated with exposure to cleaning products and found that asthma cases were reported across a wide range of job titles.89 In the report by Health Care Without Harm, “cleaners, disinfectants, and sterilants” topped the list of factors with strong evidence of asthma potential in healthcare. The report recommended implementing safer alternatives or elimination when possible.1 In a recent Brazilian study of 341 non-domestic cleaners in Sao Paulo, 11% of subjects had asthma and 35% had rhinitis, mostly related to chlorine and dust. Both asthma and rhinitis cases increased with years of employment in non-domestic cleaning.80 Asthma and rhinitis often coexist—allergic rhinitis often precedes the onset of asthma.80 Medina-Ramon and colleagues reported lower-respiratory tract symptoms on working days among Spanish female domestic cleaners. The symptoms were predominantly associated with exposures to diluted bleach, degreasing sprays/atomizers, and air fresheners.76 Thirty percent of the study subjects scored positively for work-related asthma.76 Medina-Ramon’s team also found an excess risk of both asthma and chronic bronchitis among female domestic cleaners and identified statistically significant associations for ammonia, bleach and hydrochloric acid as cleaning product exposure sources.74 In Finland, studies have shown strong evidence that cleaning work is associated with an increased risk of adult-onset

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persistent asthma.82 A large European study in 26 areas of 12 countries found that increased asthma was most consistently associated with two occupations: farmers and cleaners.83 Case reports support the evidence that toilet bowl cleaners containing the quaternary amine— benzalkonium chloride—have induced occupational asthma.73,78 Studies have also reported occupational hand dermatitis and other adverse skin effects among hospital cleaning workers.93,94 In addition to chemical hazards, cleaning is a physically demanding job with frequent awkward postures caused by poorly designed nonergonomic cleaning equipment or challenging physical work spaces. For these reasons, cleaning is a high-risk occupation for developing musculoskeletal disorders (MSDs).95-99

Exposure assessment efforts Very limited quantitative exposure assessment data exist for cleaning personnel. This is mostly because cleaning products are complex mixtures of chemicals and are a challenge to measure. In addition, most hospital health and safety studies focus on patients. The healthcare occupational health and safety studies that do exist tend to focus on clinicians rather than support staff. However having a better understanding of the exposures of cleaning staff could provide information to protect the health of patients and clinicians as well. Bello et al. propose that hospital cleaning workers may be at higher exposure risk compared to other groups of cleaning personnel because: 1) hospitals use a wide range of products including disinfectants, and 2) the frequency of cleaning activities has increased rapidly in hospitals to ensure compliance with existing regulations and guidelines for protecting patients and workers from infectious diseases.15,100 Common cleaning tasks— especially in hospitals—include: preparation of cleaning solutions, floor cleaning, window cleaning, mirror cleaning, toilet bowl cleaning, sink cleaning, and floor finishing tasks (buffing, waxing and stripping).15,86,100 Rosemann and colleagues reported that asthma cases were associated with exposure to cleaning products across a wide range of job titles.89 Bello’s study characterizing exposures to common cleaning tasks in hospi-


tals identified high-exposure jobs such as floor finishing tasks like stripping, waxing and buffing, as well as a combination of various cleaning tasks.15 Delclos and colleagues compared self-reported occupational exposures with a workplace-specific job exposure matrix (JEM) by asthma status among Texas healthcare professionals. Asthmatics’ self-reports on exposures showed better agreement than non-asthmatics’ reports with the JEM for patient-care-related cleaning tasks.92 The team recommended using externally developed methods of exposure classification.92 Human exposure to cleaning chemicals depends on many inter-related factors including chemical composition of the product, ventilation of the room, air movement and transport between the rooms, potential for dermal exposures, interactions of surfaces with cleaning products, and the methods of product application and disposal.15,100 Because there are limited occupational hygiene analyses and workplace exposure data, there is a need for systematic evaluation of cleaning products’ ingredients and their exposures in the workplace, particularly the healthcare environment. In addition, the absence of epidemiologic studies on cleaning has prevented comprehensive identification of agents responsible for asthma and other reported respiratory symptoms. What we know is that cleaning workers are at risk of acute and chronic inhalation exposures to chemical vapors and aerosols generated from product spraying, as well as dermal exposures mostly through hands.

Environmental impacts

• Bioconcentration value—the higher the value, the more likely it is to accumulate in thefood chain; • Percentage of VOCs which generate smog; • Amount of product packaging—reduced packaging decreases the amount of waste; • Presence of ozone depleting substances; • Adequate safety precautions that minimize exposure to the concentrated solution; • Flammability—non-flammable products are preferable; • Presence of cosmetic additives (e.g., fragrances and dyes)—considered to increase harmful life-cycle impacts (overall health, safety, and ecological concerns); and • Energy needs—products that work effectively in cold water reduce energy consumption.

Possible environmental impacts of cleaning products include indoor and outdoor air pollution, bioaccumulation in plants and animals subsequently affecting the food chain, endocrine disruption in wildlife, stratospheric ozone depletion, and water pollution, including drinking water quality.16 The US EPA has recommended attributes for selecting commercially available cleaning products. In addition to human health attributes (to avoid irritation and chronic health risks), environmental attributes included:19 • Biodegradation time—the faster a chemical degrades, the lower the exposure potential;


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V.

H E A LT H I E R A N D M O R E E N V I R O N M E N TA L LY F R I E N D LY C L E A N I N G F O R H E A LT H C A R E

What is green cleaning? There is no widely accepted definition of “green” or “green cleaning.”18 US Executive Order 13101—issued in 1998 by the Clinton Administration—defines “environmentally preferable” as “products or services that have a lesser or reduced effect on human health and the environment when compared with competing products or services that serve the same purpose.”17 OneSource—a provider of outsourced facilities services in the US—defines “green cleaning” as “cleaning to protect health without harming the environment.”101 Patti Costello, executive director of the American Society for Healthcare Environmental Services (ASHES) expands the “green cleaning” definition further to address the infection prevention and control efficacy “toward effective products with the fewest adverse effects on human health and the environment.”18 Even criteria for the outcomes, e.g. “protect health,” “fewest adverse effects” and “without harming the environment,” are not well established.

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mopping tasks, and 20% labor savings a day.103 Rutala and colleagues showed that microfiber mops with a regular detergent cleaner demonstrated superior microbial removal compared with cotton string mops (95% vs 68%, respectively).24

Benefits of green cleaning and examples of efforts

In general, it is difficult to find comprehensive examples of green cleaning efforts in healthcare facilities (see Appendix B). Beyond the examples provided above, peer-reviewed, scientific studies on the effectiveness of green cleaners in healthcare facilities are minimal. Nonetheless, some hospitals have engaged in encouraging green cleaning efforts. For example, two New York City hospitals—Jacobi Medical Center and North Central Bronx—reported that they instituted green cleaning programs in 2004 and replaced most of their conventional cleaning products with more environmentally preferable ones.104 One of the improvements was to replace ammonia- and chlorine-based cleaning products with products made from biodegradable, nontoxic ingredients such as soy, cornstarch and citric acid. Promising green cleaning efforts have been reported in other hospitals, for example in abovementioned Olmsted Medical Center and University of California Davis Medical Center, Hackensack University Hospital (NJ), Suburban Hospital, Bethesda (MD), and others provided in Appendix B.27,31,103,105,106

Green cleaning programs are usually undertaken to reduce adverse human health and environmental impacts. Cost savings from implementing green cleaning efforts have also been reported, including reduced overall cleaning costs, waste volumes, and need for storage space.102 Among others, the Olmsted Medical Center (Rochester, MN) expected their annual cost savings to reach more than $20,000 through reduction of unnecessary chemicals, process improvements developed by standardizing cleaning and disinfecting procedures, and eliminating redundant chemical use.31 Another example is the University of California Davis Medical Center (Sacramento, CA) which experienced the following benefits by replacing conventional mops with microfiber mops: 60% lifetime cost savings for mops, 95% reduction in chemical costs associated with

The transition from conventional cleaning products to safer alternatives in the healthcare sector is complex. While some green cleaning products may have fewer health effects and be more environmentally sound, the purchase of green cleaning products does not assure the overall reduction of risks. The main reasons include: a) there are little data about the hazards associated with specific green cleaning products; b) certification of green products was initially based on environmental performance and only recently have health effects been taken into account (e.g., revised Green Seal GS-37 standard); and c) potentially harmful cleaning exposures are not only a function of the product characteristics, but also a function of the way that the products are applied and disposed. This latter point is seldom addressed in current discussions of green cleaning.


From an infection prevention and control perspective, it is not clear whether green cleaners are effective in reducing or eliminating micro-organisms at the level needed for a particular application. Patti Costello, executive director of the American Society for Healthcare Environmental Services, stressed that changing approaches without sufficient research and data on the efficacy of alternative greener procedures and products is simply trading one set of problems for another:107 “We are an environmental group, so for us not to encourage our members to be involved in caring for the environment would be against who we are, but our number one priority is patient safety and infection prevention …The clean needs to come first, and then you work on being green. And there are many ways to do that. From where we sit, you need to remove visible soil and dirt, and for that, a neutral detergent is okay. But for high-touch areas and patient care areas, you need to clean and disinfect. Disinfectants, by their very nature, kill microorganisms. I’ve never seen a green disinfectant, and I doubt if we ever will. That is not to say that cleaning procedures and products can’t be effective and greener… There’s a lot of [environmentally friendly] technology out there, and everyone is striving to find the most effective solutions. But there’s a lot of research and data and peer review that needs to take place before you can jump on the ‘bandwagon of the day’ as it relates to green.”107

Cleaning, disinfecting, and antimicrobials products This document provides the Centers for Disease Control and Prevention (CDC) definitions for cleaning, disinfection, sterilization, and antimicrobials in the Background section. In 2003, the CDC provided more specific guidelines for environmental infection prevention and control in healthcare facilities, including principles for cleaning and disinfecting environmental surfaces.36 The guidelines reinforced cleaning as the necessary first step of any successful disinfection or sterilization process. For housekeeping surfaces in patient care areas, the guidelines (p.74) highlight the importance of carefully considered cleaning 36:

“Most, if not all, housekeeping surfaces need to be cleaned only with soap and water or a detergent/disinfectant, depending on the nature of the surface and the type and degree of contamination. Cleaning and disinfection schedules and methods vary according to the area of the healthcare facility, type of surface to be cleaned, and the amount and type of soil present. Disinfectant/detergent formulations registered by EPA are used for environmental surface cleaning, but the actual physical removal of microorganisms and soil by wiping or scrubbing is probably as important, if not more so, than any antimicrobial effect of the cleaning agent used.” In 2008, the US-CDC adopted The Guideline for Disinfection and Sterilization in Healthcare Facilities which presents evidence-based recommendations for healthcare cleaning and disinfecting as well as preferred methods for cleaning, disinfecting and sterilizing medical devices.35 The 2008 CDC Guideline emphasizes Spaulding’s* rational approach categorizing patient care items as critical, semi-critical, and non-critical according to the degree of infection risk involved in their use.35 It categorizes such surfaces as bed rails, bedside tables, patient furniture, and floors as non-critical. However, it also refers to them as high-touch surfaces that could contribute to secondary transmissions by contaminating hands of healthcare workers or by contacting medical equipment that subsequently contacts patients.35 US EPA considers antimicrobial products** to be pesticides, and requires their registration as stipulated under the Federal Insecticide, Fungicide and Rodenticide Act (FIFRA).28,37 In the US, there are no specific standards for antimicrobial products. The US EPA does not allow manufacturers who add antimicrobials/fungicides to their products to make “health claims” (e.g., prevents spreading germs or harmful micro-organisms), 108,109unless registered as a pesticide by the EPA under FIFRA. To obtain registration, an antimicrobial product must not cause “unreasonable adverse effects to human health or the environment,” and its labeling and composition must comply with * In 1968, Earle H. Spaulding developed an approach to

disinfection and sterilization of patient care items and equipment. 35 ** Except antiseptics and germicides.


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FIFRA requirements.37 In addition, manufacturers must provide detailed information on the product’s chemical composition, documentation of its effectiveness against specific microorganisms, and any hazards associated with the product’s use.37 At the moment, the EPA does not allow anti-microbial products to be marketed as green because of their inherent ability to kill micro-organisms.110 However, the EPA has started to explore possibilities for a policy change to allow green claims for nonporous hard-surface disinfectants and sanitizers; as a first step, the EPA’s Office of Pesticide Program (OPP) and its Design for the Environment (DfE) Formulator Program will conduct an internal pilot to evaluate cleaning products that the DfE has already recognized imitating antimicrobial products.111 If the results of the internal pilot are beneficial, the EPA anticipates conducting an external pilot with the cleaning industry representatives and distributors.111

tion, accounting, records, human resources, patient registration and waiting, shops, carpentry, mail, printing, materials management, hallways); approximately 25- 45% is considered medium-infection-risk zones (e.g., areas such as public restrooms, nursery, outpatient clinics, diabetes clinics, and respiratory clinics, physical therapy, and cardiac rehabilitation); and about 10% is thought to be high-infection-risk zones (emergency, labor and delivery, morgue, surgery).112 The determination of zones begins with the patient risk and moves outward into lower risk areas or zones. The Practice Greenhealth Guide stated that more is not better with disinfection: excess product use increases occupational and environmental risks without improving infection prevention and control effectiveness.27

The most commonly used antimicrobial products in healthcare include disinfectants, sterilizers, sanitizers, antiseptics, and germicides.28,37 Disinfection and sterilization are defined in Section III. Sanitizers reduce, but not necessarily eliminate, microorganisms from the inanimate environment to levels considered safe by public health codes or regulations (e.g., products for food items, carpet sanitizers, air sanitizers, laundry additives, in-tank toilet bowl sanitizers).37 Antiseptics and germicides are used to prevent infection and decay by inhibiting the growth of microorganisms; because antiseptics and germicides are used in or on living humans or animals, they are considered drugs and generally not antimicrobials, thus, approved and regulated by the US Food and Drug Administration (FDA).37 More than 5,000 antimicrobial products are currently registered with the EPA and available in the market. Nearly 60% of these products are registered to control infectious microorganisms in the healthcare sector.37 Not surprisingly, there have been concerns about the overuse of antimicrobials in healthcare facilities. In a typical hospital, about 45-65% of the facility space is considered to belong to low-infection-risk zones (e.g., areas belonging to exterior maintenance, administra-

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VI.

SYSTEMS APPROACH

A comprehensive systems approach that includes both the influences of the broader society in which healthcare is being delivered as well as the individual healthcare facility is needed to identify effective points of intervention for more healthy, safe, and environmentally sound cleaning. The idea behind the systems approach is that there are relevant interdependencies and interrelationships between representatives inside of and external to a workplace/organization that create change. Various scientists and policy makers have used a systems approach to conceptualize their cases.113-117 For cleaning in healthcare, the systems approach is needed to identify and balance all of the influences, overt or subtle, that ultimately affect the choice of cleaning products and practices. Only with this broader understanding will effective and continuously improving cleaning strategies be achieved. While intra-hospital relationships related to cleaning are recognized fairly readily (e.g., groups and individuals involved in procurement, use, disposal, infection preventionists, clinical staff, administrators), there are other powerful external driving forces for selecting cleaning products and practices that must be considered. For example, hospital infection prevention and control practices are likely to be influenced by the Centers for Medicare & Medicaid Services (CMS) recent plan to stop paying additional funds for certain preventable medical errors or conditions that result in serious consequences for the patient, including specific HAI. Another related issue is the intensive interest in HAI in general and the consumer’s awareness of multi-drug resistant organisms (MDROs) in light of the heavy media coverage on MDROs like Methicillin-resistant Staphylococcus aureus (MRSA). Consequently, these influences bring further skepticism towards green cleaning products and practices.

An opposing influence is the widespread adoption of the Leadership in Energy and Environmental Design (LEED) certification program (see Section VII), which includes guidance for the design and operation for highperformance green buildings. The LEED for Existing Buildings (EB) Rating System also helps building owners and operators measure the green performance of existing operations, including whole-building cleaning strategies. The LEED supports green cleaning products and practices. Currently there is very little information describing cleaning from this macro perspective. However the most effective strategies for cleaning vis-à-vis the three safeties –environment, patient, and employee—will be attained only with this broader view. Several groups have developed methods to apply a systems approach to cleaning at the level of the healthcare facility. Stephen Ashkin, president of a consulting firm specializing in green cleaning, says “the plan matters” and poses the following questions: (i) How is the facility defined for cleaning purposes? (ii) Are all tasks at one level of cleaning? (iii) Are different cleaning standards needed for different areas—i.e. high infection risk; medium infection risk, and low infection risk areas? 112 Ideally, one would have a clear understanding of the appropriate level of cleanliness and how to achieve it (Table I). In reality, healthcare facilities are faced with a dizzying array of cleaning products and methods. Many of these cleaning products may not be provided with adequate guidance on how to achieve the desired cleaning outcome and what the tradeoffs might be.


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Table I: Achieving the Desired Cleanliness Considerations What is the desired state of cleanliness?

What level of cleanliness is warranted or desired? How would it be measured? How will we know when the desired level is attained?

What is the current state of cleanliness?

What is the baseline level?

How can the gap be closed, between the current cleanliness and the desired state?

What types of cleaning products or methods are effective for moving from the baseline condition to the desired outcome?

What needs to be prevented, removed or inactivated in a particular area (e.g., soil, grease, bacteria, odors, etc.)?

What are the cleaning products/methods that address specific needs (e.g., removal of soil, grease, bacteria, odors)? What constraints exist (e.g., physical limitations, occupied space, food preparation surfaces)? How does one find, evaluate and select the products or practices? How does one assess and weigh the merits and shortcomings of the alternative products and practices?

SHP experience with a systems approach to changing practices in hospitals The SHP developed a participatory strategy for working with hospital staff (administrators, clinicians, clinical laboratory managers and technicians, facilities managers and housekeeping) to assess the use of hazardous materials and practices and to identify and implement safer, more environmentally sound alternatives. The approach is called the Pollution Prevention-Occupational Safety and Health alternatives assessment, implementation and evaluation strategy (P2OSH strategy) which integrates environmental and occupational safety and health.7 An integrated strategy is essential because workplace changes in materials and practices cannot be maintained without accounting for the work functions and without getting employee input and buyin early in the change process. Lessons learned from conducting green cleaning and other pollution prevention activities in US hospitals indicate that focusing on the environment without accounting for the workplace often will not be effective. A successful green cleaning program must (i) be fully supported by the management, and (ii) involve administrators, clinicians, infection preventionists, safety officers, housekeeping/

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environmental services, and clinical laboratory personnel to evaluate the infection prevention and control, occupational health, and environmental performance of the new cleaning program. The integrated P2OSH strategy was developed over the past decade in response to hospital workers’ observations that pollution prevention solutions can inadvertently introduce new occupational health problems, and vice versa. This is sometimes referred to as “risk shifting,” when a solution in one area causes problems in another. Because occupational and environmental hazards arise from the same sources, user-friendly and sustainable solutions require an integrated systems approach. Few alternative products can be categorized in absolutes of “good” or “bad” with respect to the environment and health. Hence, P2OSH is the process by which one considers the merits and shortcomings of alternative products. In this way, the hospital can make an informed choice of the alternative that best suits its situation. When a new alternative becomes available, perhaps offering more benefits and fewer shortcomings, the process to implement and evaluate it is repeated in a cycle of continuous improvement. Thus training of hospital staff focuses on gaining skills that can be used long after the original alternative substitution is accomplished.


Figure 1: The Sustainable Hospitals Program P2OSH alternatives assessment and implementation strategy7

Identification

Establish P2OSH team

Identify materials/processes to be replaced (P2OSH intervention target)

Research and screen alternatives (Potential interventions)

Implementation

Pilot one alternatives (Interventions)

Unacceptable

Acceptable

Implement alternative full scale


Process change

Evaluate alternative

No process change

Conduct post- intervention worksite assessment Evaluation of effectiveness

Stages in OSH Intervention Research

Conduct pre-intervention worksite assessment

Continuous improvement

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Practice Greenhealth approach

Management and the team

Practice Greenhealth has used a systems approach and developed a 10-step green cleaning program.27 It was designed for busy employees at healthcare facilities who don’t have a lot of time to spend reading background material. The Guide includes policy development, selection of products, staff training, standardized operations, cleaning equipment and supplies, and the program monitoring.27 The Practice Greenhealth approach includes the following steps27:

Any systems approach, program, or management system requires two crucial features: (i) commitment of management and (ii) involvement of worker representatives affected by the change. Both the above SHP and Practice Greenhealth approaches prioritize the support of management and careful selection of team members because the strength and cohesion of the team defines the success of future steps.

• Step 1: Form a team and gain commitment; • Step 2: Review current products and practices (conduct inventories of cleaning products, equipment, policies, and operations); • Step 3: Evaluate and categorize facility areas (identify high risk, medium risk, and low risk care areas, patient rooms); • Step 4: Determine evaluation criteria for products and operations (review product attributes, GPO contracts, certified products, and changes in operations); • Step 5: Select products (e.g., general, toilet bowl, carpet, and glass cleaners have been certified under Green Seal GS-37 and GS-40 products; floor strippers and waxes; and types by usage of disinfectants); • Step 6: Develop a pilot plan (pilot area(s), pilot evaluation criteria, feedback solicitation, changes in work processes, pre-implementation and postimplementation surveys for facility staff, patients and visitors);

Who should be included as members of the green cleaning team? At a minimum, the team should consist of representatives from operational areas affected by the green cleaning program, including (not limited to): management/administration, clinical staff (at least one physician, nurse, nurse aide), infection preventionists, safety officers, occupational and environmental officers, operations and facilities personnel, housekeeping/environmental services, purchasing department staff, and laboratory personnel. Marketing, community relations, and GPO representatives may also play useful roles in green cleaning teams.112 While the team serves as the working group for moving green cleaning forward, the role of management cannot be understated. Most improvement activities consist of a series of successes and obstacles, and steps backward are as common as progress. It is the responsibility of management to reinforce the process and provide the resources that allows the team to move forward. These resources include not only the obvious manpower and finances, but space, time, and moral support.

• Step 7: Execute the pilot (incl. training and feedback); • Step 8: Evaluate the pilot (post-pilot surveys for staff, patients, visitors) • Step 9: Celebrate success (develop press releases, case studies, and materials for future green cleaning projects); and • Step 10: Expand your efforts by institutionalizing the program (e.g., facility’s cleaning chemical purchasing standards excluding products containing toxic chemicals in favor of safer products successfully used).

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VII.

GREEN MOVEMENTS I N T H E H E A LT H C A R E S E C TO R

LEED for Healthcare Many factors are prompting the healthcare sector to develop and implement sustainable and green initiatives, including green cleaning programs. One of the most visible and influential factors is the impending launch of the new Leadership in Energy and Environmental Design (LEED) for Healthcare29 certification program by the US Green Building Council (USGBC) that is tailored to healthcare facilities. This evolved from the USGBC’s LEED Green Building Rating System, developed in the mid-1990s.30 Efforts began in 2002 for the healthcare version, which led to the collaboration of the contributors to the Green Guide for Health Care sustainable design toolkit (GGHC) and the USGBC, resulting in the development of LEED for Healthcare29 expected to be finalized and launched in the second quarter of 2009.20 It is expected that LEED for Healthcare will become a de facto standard for healthcare facilities, similar to the widespread acceptance of the original LEED for New Construction standard for green buildings. “Environmentally Preferable Cleaning” is a part of the Environmental Services (ES) operations credit of the GGHC29 and is divided into three specific subsections: policy development, products and materials, and cleaning equipment. The credit rating requirements have been outlined for all three subsections. The GGHC recommends extensively cleaning products and materials certified by the US Green Seal and Canadian Environmental Choice.

Green cleaner certification programs Several organizations offer green certification of cleaners to meet recognized green standards. This has proven to be a powerful force in the transition to green cleaning practices. Green Seal, the most visible of the US organizations, is an independent, non-profit organization that evaluates and certifies green products. Green Seal has developed two standards for cleaning products: GS-37118 for industrial and institutional cleaners and GS-40119 for industrial and institutional floor-care products. The GS-37 standard was revised in April 2008 with new requirements regarding human health and environment, including: 120 prohibiting asthmagens; including additional inhalation exposure criteria with inhalation toxicity limits; prohibiting carcinogens, mutagens, reproductive toxins, phthalates (a group of endocrine disrupters), and 2-butoxyethanol; tightening VOC content limits to provide additional in-door air protection (1% in glass and carpet cleaners); increasing acute oral toxicity limits; inclusion of bioaccumulation criteria; disclosure of fragrance use; and other. Over 150 manufacturers attained the earlier GS-37 certification (pre-April 2008) for their institutional cleaning products and 75 manufacturers have floor products with GS-40 certification. (See Appendix C) In addition to Green Seal, other well-recognized green product certification programs include the Canadian Environmental Choice (also called EcoLogo) program, the US EPA’s Design for the Environment (DfE) Formulator Program, Cradle-to-Cradle, the Nordic Swan, EcoLabel (European Union), and Blue Angel (Germany).19 Appendix C provides a very short list of selected sources that are useful to start identifying and choosing industrial green cleaning products.


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Many facility managers trust that certified products are healthier for building occupants and the environment.110 However, as noted earlier, one group of products, cannot be certified as green. The US EPA prohibits manufacturers or distributors from promoting, labeling, or marketing disinfectants or any other antimicrobial pesticides as green (see the subsection entitled Cleaning, disinfecting, and antimicrobials products of Section V) and stipulates that registration under FIFRA is sufficient assurance of safety and effectiveness and that any additional claims may be misleading.110 Disinfectant users, including hospitals, are seeking safer disinfectants than FIFRA-registered ones and as a result, cleaning industry representatives are discussing with the EPA how to promote safer disinfectants.110 The EPA is exploring possibilities for a future policy change for nonporous hard-surface disinfectants and sanitizers (the subsection of Cleaning, disinfecting, and antimicrobials products of Section V).111 At the moment, hydrogen peroxide or hydrogen peroxide-peracetic acid are considered a more benign disinfectant than those containing chlorine or phenolic compounds, or 2-butoxyethanol.28,55,110 The Canadian Environmental Choice Program (EcoLogo) has developed certification criteria for disinfectants and disinfectant-cleaners (Standard CCD-166). The Standard lists numerous prohibited and restricted components as well as toxicity and degradability requirements.121

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VIII.

M O V I N G U P S T R E A M T O WA R D S N O N - C H E M I C A L A LT E R N AT I V E S

Successful green cleaning programs should move upstream in the cleaning process towards non-chemical or less toxic alternatives by identifying new technologies, building materials, and work practices without compromising infection prevention and control goals. The INFORM, Inc. report “Cleaning for Health” has suggested that the use of hazardous chemicals could be reduced by 13% if cleaning staff used fewer chemicals, substituted less toxic chemicals, increased the use of entry mats, and avoided aerosol products.28,55 The use of microfiber mops and cloths has been shown as effective and safe103 while reducing noise pollution from vacuums. The entire building and its operational design should be considered for environmentally friendlier cleaning. In her white paper to the American Society for Healthcare Engineering Annual Conference, Bartley discusses good practices and recommends heeding the “three safeties (i.e, patient, employee, environmental safety)” principle with such practices as108: (i) Provide private patient rooms. From the infection prevention and patient safety perspective, private patient rooms have been associated with reduced medication errors, falls, and HAIs. (ii) Focus on water. Routine maintenance and prompt response to water leaks prevent moisture and consequent fungal formation inside the buildings. Also, sink designs can reduce splashing and waterborne pathogen infection risks.122 (iii) Reduce waste by implementing recycling and takeback programs; and (iv) Use microfiber mops with detergents instead of cotton mops with disinfectants. Other environmentally friendly cleaning strategies include: choosing surface materials that are easy to maintain and clean with the greenest products available to minimize worker or patient exposure to cleaning and disinfecting products; designing heating, ventilation, and air conditioning (HVAC) systems that remove airborne contaminants; designing rooms, floors, toilets/bathrooms so that they can be cleaned with a minimum of chemicals; and organizing waste manage-

ment.123 For example, HVAC- systems in healthcare facilities can be designed to maintain comfortable indoor temperature and humidity to control odors, remove air contaminants, and minimize the risk for transmission of airborne pathogens such as M. tuberculosis.36 Studies report ultraviolet germicidal irradiation (UVGI)* technology as an effective method in the fight against infections in healthcare, however, there are safety tradeoffs (i.e., ultraviolet radiation exposure).124-125 The CDC guidelines recommend UVGI as a supplemental air-cleaning measure but it cannot replace HEPA filtration systems which are considered at least 99.97% efficient for removing particles greater than 0.3 micrometers (μm).36 The UVGI technology is said to be effective in reducing the transmission of airborne bacterial and viral infections, for example, in hospitals, but has only a minimal inactivating effect on fungal spores.36 Many cleaning experts recommend focusing on exterior facility maintenance (i.e., keeping the contaminants out of the facility) and entryway systems and maintenance (i.e., capturing the contaminants at entryways).27,112 Cleaning technologies that remove soil, dust, mold, and allergens non-chemically are the most preferable. For example, over 80% of the soil enters through shoe soles, hence, proper high-performance matting systems in entranceways are needed to capture, trap and retain the soils.123 A high-performance matting system allows the soil and contaminants to fall beneath the surface of the mat, preventing tracking into the facility and reducing the need for chemical cleaning. The USGBCLEED EB standard awards one point (of the necessary 32) to facilities that have an effective, high-performing matting system in place.123 Another effective tool that complements and reduces chemical cleaning is the use of vacuum cleaners with true HEPA filtration, designed to capture fine particulate matter and dust through a multistage filtration process.123

* the use of ultraviolet radiation to kill or inactivate microorganisms.


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There are truly promising reports from healthcare facilities using microfiber mops.7,21-24 As earlier indicated, investigation by Rutala shows that the microfiber mop can sequester and remove microorganisms with a detergent cleaner—it is not necessary to use disinfectants. These mops provide a safer, greener, and effective method of cleaning. Microfiber mops demonstrated superior microbial removal compared with cotton string mops (95% vs 68%, respectively).24 The microfiber mop is lightweight, compact, and offers ergonomic, infection prevention and control, as well as inventory management benefits compared to a conventional mop and bucket system. In microfiber mopping, a fresh cleaning pad soaked in cleaning solution is used for each room. The soiled pad is then set aside for laundering, maintaining the cleanliness of the virgin cleaning solution and preventing cross contamination of rooms.103 The design of the microfiber system eliminates the need to mix, transport, and refresh large buckets of cleaning solution, eliminating lifting and carrying of heavy buckets and minimizing the use of cleaning chemicals and water.103 An additional benefit of microfiber mopping is that patients are happier because microfiber mopping is quieter, faster and less intrusive.22

Green cleaners are only one spoke of the wheel. To achieve the most successful outcome, cleaning products need to be considered together with all other contributors to a clean healthcare setting. Otherwise, one of the fundamental three safeties—patient, employee, environmental—will be compromised.

Last but not least, proper cleanliness as well as infection prevention and control start with hand hygiene. Prevention Strategist* described how money-saving technologies like motion-sensitive lights, doors, faucets, soap and paper towel dispensers, etc can also reduce infections since germs on patients’ and healthcare workers’ hands are not spread around.126 Christopher Tricozzi** makes a useful analogy that summarizes our approach to green cleaning. He noted in a roundtable discussion*** that green cleaning is not only about cleaning chemicals and that healthcare administrators should view all the different elements of green cleaning as “the spokes on a wheel: 123 “As long as all the spokes are strong and sturdy, the wheel works fine. But when one is missing or is not performing correctly, the integrity of the entire wheel may be in jeopardy.” 123

* A publication of the Association for Professionals in Infection Control and Epidemiology (APIC) ** Industry representative from Crown Mats and Matting *** Organized by the Infection Control Today Magazine: http://www. infectioncontroltoday.com/articles/green-cleaning-roundtable.html

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IX.

CONCLUSIONS A N D R E C O M M E N DAT I O N S

The knowledge gaps pertaining to attaining and maintaining cleanliness in healthcare settings include the following:

Cleaning in general • We know that the use of some cleaning products is related to asthma and asthma-like symptoms. What we lack are adequate data on which specific ingredients cause asthma or other health effects. • Studies have shown that respiratory and dermal exposures result from a combination of factors including the cleaning products used, ambient conditions, physical space, and the way tasks are performed (e.g., sequential toilet, mirror and floor cleaning). There is limited information about how cleaning tasks generate respiratory and dermal exposures. • There is a need to develop a universal standard to test cleaning and/or disinfection effectiveness in different laboratories and workplaces. No single product will work for every situation and processspecific testing is a necessity before switching to a new product. • It is important to have a comprehensive analysis of the broad system of cleaning, including its decisionmakers, their roles, and responsibilities at various levels of work organization. A such analysis currently does not exist.

Green cleaning • While we found many general descriptions of green cleaning, there is no uniform definition of green cleaning for the healthcare sector. “Cleaning to protect health without harming the environment”101 is frequently used; however, it is not adequate for the healthcare sector as it leaves out the concept of cleaning effectiveness, most notably infection prevention and control.18 • In healthcare it is crucial to understand how cleaning practices support infection prevention and control goals. Our literature search showed that there

are no systematic scientific evaluations publicly available on how effectively green cleaners meet infection prevention and control standards. • Other public health issues have demonstrated that readily available information rapidly advances the adoption of good practices and lessons learned. For example, significant mercury reduction was achieved in US hospitals over the past decade largely as a result of strong communication on programs to eliminate mercury. However there is no similar publicly available information on green cleaning programs in healthcare facilities with details of how they were implemented and the lessons learned. All that are currently available are rather short reports.27,104 We recommend the development of a central national repository providing comprehensive information on green cleaning in hospitals. (see Appendix B) • While green cleaners offer great promise for human health and the environment, we can find no evidence of comprehensive scientific health studies that examine health risks from green cleaners.

Upstreaming non-chemical alternatives for cleanliness • Architecture and the use of green building materials are an important avenue for attaining and maintaining cleanliness in healthcare settings. Integrating prevention through design with cleaning methods should be considered as part of a unified system to reduce exposures and promote sustainable solutions; • Many new materials, technologies and approaches for attaining and maintaining cleanliness are coming onto the market with little information about risks or potential harms. These need to be considered using a systems approach that examines their efficacy for cleaning, as well as infection prevention and control and how these products interact within the broad system of cleaning to avoid risk shifting among patients, workers, and the environment.


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New research and educational initiatives could fill many of the gaps listed above. LEED for Healthcare is expected to be launched during the 2nd half of 2009 so the period of 2009-2010 is timely for collecting baseline occupational exposure and health data. The baseline data can be compared to the LEED post-implementation data to measure the success. The following recommendations flow from the knowledge gaps. They are not meant to be a definitive list: • Qualitative study: We recommend carrying out a qualitative study on the nature, effectiveness, and impacts of environmentally friendly (green) cleaning programs in selected hospitals by conducting (i) in-depth interviews with key staff members who coordinate or participate in green cleaning teams and (ii) focus groups with janitorial employees in these same hospitals. The SHP’s research on sharps injuries in home healthcare127 demonstrated that qualitative data provide crucial in-depth information on the nature of the study topic as well as how it is influenced by different circumstances, perspectives, and social forces. These qualitative data are needed to fully define the main influences in the system of cleaning in healthcare and to identify gaps and lessons learned for information rich case studies. • Exposure assessment: The SHP’s earlier work on exposure assessment of cleaners attests to the need and offers a baseline for conducting exposure assessment studies to develop improved work practices and cleaning. It is recommended that a study be designed and conducted to assess worker exposures with green cleaners and typical work scenarios. • Conduct human health studies on green cleaning products focusing on asthma and other health effects. • Collaborate with infection preventionists and microbiologists to design studies and standard methods to evaluate how effectively green cleaners meet the infection prevention and control goals.

scientifically based. What the SHP has found is that over time a repository like this amasses a collection of useful information from different sources that complements and builds upon itself. • How-to guidance: We recommend that information about the selection and use of green cleaners be developed into a series of 2-page factsheets for frontline workers. While journal articles are important for communicating to the scientific community, frontline workers have informed the SHP that terse and cogent how-to guides are useful for understanding and getting buy-in for improvements to their practices. The SHP currently has over two dozen fact sheets on various health and safety topics and these are some of our most requested products for conferences, hospital outreach and educational events. One of these, “10 Reasons to Use Microfiber Mopping”, presents a broad overview of considerations and cautions for hospitals considering this alternative. • Case studies: In addition to articles and factsheets, the SHP recommends the use of case studies to serve as practical overviews of implementing new products or practices. The case studies differ from the factsheets in that they are more detailed, comprehensive, and useful to a broader audience within the healthcare setting. The SHP’s “Case Study: Are Microfiber Mops Beneficial for Hospitals?”23 is an example of a systematic examination of environmental, safety and health aspects of microfiber mopping. • Train janitors, housekeepers, unions and labor groups on the systems approach to green cleaning. • Develop materials on health and environmental aspects of cleaning for hospital administrators and managers.

• Clearinghouse on green cleaning: A freely accessible, online central repository of information about green cleaning is a necessary and powerful force for identifying and sharing best practices, creating a driving force for the development and promulgation of up-to-date and scientifically based information, and provide mentoring for hospitals lacking in resources. Two important characteristics of this clearinghouse are that information is free and

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117. Markkanen, P, Levenstein, C. New points of production: homework and shoemaking in Asia. New Solut 2004. 14(4):301-18. 118. Green Seal, I. Green Seal™ Environmental Standard for Industrial and Institutional Cleaners (GS-37), 2008. Available at: http:// www.greenseal.org/certification/standards/GS37_Industrial_ Cleaner_Standard.pdf. Accessed: 04/02/09. 119. Green Seal, I. GS-40 Green Seal™ Environmental Standard for Industrial and Institutional Floor-Care Products, 2004. Available at: http://www.greenseal.org/certification/standards/industrial_ institutional_floor_care_GS_40.pdf. Accessed: 04/02/09. 120. Green Seal, I. GS-37 Update: Green Seal™ Environmental Standard for Industrial and Institutional Cleaners. 2008.Green Seal website. Available at: http://www.greenseal.org/resources/ gs37_overview.pdf. Accessed: 04/02/09. 121. Environment Canada’s Environmental Choice Program. Certification Criteria Document: CCD-166. Product: Disinfectants and Disinfectant-Cleaners. 2008. Available at: http://www.ecologo. org/common/assets/criterias/CCD-166.pdf. Accessed: 04/02/09. 122. Hota, S, Hirji, Z, Stockton, K, Lemieux, C, Dedier, H, Wolfaardt, G, Gardam, MA. Outbreak of multidrug-resistant Pseudomonas aeruginosa colonization and infection secondary to imperfect intensive care unit room design. Infect Control Hosp Epidemiol. 2009. 30(1):25-33. 123. Pyrek, KM. Green Cleaning and Infection Control: An Expert Roundtable Discusses the Issues. Infection Control Today 2008. Available at: http://www.infectioncontroltoday.com/articles/ green-cleaning-roundtable.html. Accessed: 01/23/09. 124. Schafer, MP, Kujundzic, E, Moss, CE, Miller, SL. Method for estimating ultraviolet germicidal fluence rates in a hospital room. Infect Control Hosp Epidemiol. 2008. 29(11):1042-7.

108. Bartley, J. Facility managers dilemmas: crossroads for infection prevention, green, and safety. White paper. American Society for Healthcare Engineering Annual Conference. American Society for Healthcare Engineering Annual Conference. Washington DC. July 22, 2008.

125. Leung, M, Chan, AH. Control and management of hospital indoor air quality. Med Sci Monit. 2006. 12(3):SR17-23. Epub 2006 Feb 23.

109. US Environmental Protection Agency. Consumer products treated with pesticides. 2008.EPA website. Available at: http:// www.epa.gov/pesticides/factsheets/treatart.htm. Accessed: 04/02/09.

127. Markkanen, P, Quinn, M, Galligan, C, Chalupka, S, Davis, L, Laramie, A. There’s no place like home: a qualitative study of the working conditions of home health care providers. J Occup Environ Med. 2007. 49(3):327-37.

110. BioCanadian. Are There Green-Certified Disinfectants? 2009. Press release on BioCanadian website. Available at: http:// www.biocanadian.com/english/press/tag/green-disinfactants. Accessed: 04/02/09.

126. Latter, C. Green by design. Prevention Strategist. Publication of APIC Inc, Washington DC. 2008. 1(4):36-40.

111. The Ashkin Group. EPA announces “internal pilot” for green disinfectant claims. Infection Control Today 2009. Available at: http://www.infectioncontroltoday.com/hotnews/green-disinfectant-claims.html. Accessed: 04/02/09. 112. Ashkin, SP. Green cleaning in hospitals: cleaning to protect health without harming the environment Available at: www.h2e-online. org/pubs/grncleaning.ppt. Accessed: 04/02/09. 113. Wooding, J, Levenstein, C. The Point of Production: Work Environment in Advanced Industrial Societies. New York: The Guildford Press, 1999. 114. Hermans, LM. Dynamic actor network analysis for diffuse pollution in the province of North-Holland. Water Sci Technol 2004. 49(3):205-12. 115. Timpka, T, Bang, M, Delbanco, T, Walker, J. Information infrastructure for inter-organizational mental health services: an actor network theory analysis of psychiatric rehabilitation. J Biomed Inform. 2007. 40(4):429-37. Epub 2006 Nov 17. 116. Williams-Jones, B, Graham, JE. Actor-network theory: a tool to support ethical analysis of commercial genetic testing. New Genet Soc. 2003. 22(3):271-96.

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A.

APPENDIX A: EXAMPLES OF HAZARDOUS INGREDIENTS IN CONVENTIONAL CLEANING PRODUCTS

The below table is a modified version published by Bello et al in Environmental Health, 2009.1 At the end, the table by Premier Safety Institute clarifies bleach dilutions with household measurement terms.2

Name

Chemical formula

Physicochemical properties

Examples :

Boiling point (BP): 205 0 C

OH

Respiratory , skin, mucous membrane (eye) effects

Other health effects

Purpose of use in cleaning products

Isopropyl alcohol: Highly volatile. Irritant to eyes and the upper respiratory tract. Prolonged exposure may cause lung damage.3

Benzyl alcohol has been reported as a contact allergen in cleaning products.5,6

Used as solvents and disinfectants in cleaning products.4

Highly irritating. Inhalation of its vapors can irritate the nose, throat, and lungs, causing wheezing and shortness of breath. Prolonged exposure can cause bronchitis.3,7

No evidence of sensitization was found.1

Used in glass cleaners.1

Breathing its vapors can irritate the nose, throat and lungs, causing coughing, wheezing and shortness of breath.3

Exposure to ethanolamine has been associated with occupational asthma.9

Used as surfactant in cleaning products.1 Used in floor care products, general purpose, glass, and bathroom cleaners.1

2-BE is a toxic chemical.8 Ethylene glycol alkyl ethers target the central nervous system, blood and bloodforming organs, and reproductive system.10

Used as solvent in cleaning products to dissolve fatty substances.1 Mostly used in glass, general purpose cleaners, and floor care products.1

Alcohols

Benzyl alcohol OH

BP: 82.5 0 C

Isopropyl alcohol

Ethanol and isopropyl alcohol are absorbed through the skin and can irritate the skin, eyes, upper respiratory tract, and throat.4

Ammonia

CH3CH2OH Ethanol (ethyl alcohol) Found in aqueous solutions in the form of ammonium hydroxide.

NH3

(BP): -33.5 0 C

Ethylene glycol ethers

Ethanolamine

BP: 170.8 0C H2N

OH

Ethanolamine (MEA, mono-ethanol amine, 2-aminoethanol),

It is a skin irritant and can be absorbed through the skin.8 Can cause skin sensitization.3

Examples : OH O

CH3

2-Buthoxyethanol (2-BE, ethylene glycol monobutyl ether, butyl “Cellosolve)

2-BE (BP):168 OC

2-BE vapors are irritants to eyes and respiratory tract.10 Class A3 : Confirmed animal carcinogen with unknown relevance to humans.11 2-BE is a skin irritant. Absorbed in the body through skin12 - an important exposure route.13


31

In organic Chlorine compounds

Name

Examples:

Bleach is highly toxic when mixed with ammonia or ammonium quaternary compounds, generating chloramine gas.4 Can form chlorine gas when mixed/ used in conjunction with strong acids (e.g., toilet bowl cleaners).4 Fire risk in contact with organic materials.8 Store separately from other cleaning products.

Breathing a high concentration of chlorine can irritate the lungs.4 Particularly dangerous for people with heart conditions or chronic respiratory problems such as asthma or emphysema.4 Concentrated hypochlorite can cause corrosive damage to the skin and nails. Concentration below 5.25% not corrosive unless exposure occurs over a long period.4

Strong tissue irritant.8 Concentrated bleach can cause corrosive damage to the eyes and mucous membranes.4 Chlorine bleach often manufactured using a mercury cell process, leaving contaminant mercury in the product.4

Bleach is a commonly used disinfectant in medical, commercial, and household settings.1

Concentrated solutions are highly reactive and have low flash points.4 Explosion hazard and must be stored carefully and away from other combustible materials and other chemicals.4

Corrosive to the skin over 50% concentrations, irreversible eye damage over 10% concentrations.4 Ready-to-use dilutions contain less than 2% percent hydrogen peroxide - which is not irritating to the skin unless other irritating ingredients are present. At high concentrations, irritates the nose, throat, and lungs.4

Classified as “mutagenic,” however, no evidence that exposure to the concentrations found in cleaning products would cause mutagenic damage in humans.4

Hydrogen peroxide considered more green due to fewer toxic characteristics than, for example quaternary ammonium or chlorine compounds.4

Irritant to eyes and respiratory tract when inhaled.14 Even at low concentrations is extremely irritating to the skin. Repeated skin contact can cause dryness, itching and redness. Can penetrate the skin.3

Sensitivity potential reported from animal studies.15 OPP is listed as a carcinogen in California.4,16

Phenols are used as disinfectants in cleaning products – many considered effective against tuberculosis.17

Benzalkonium chloride suspected gastrointestinal and liver toxicant, and other quaternary ammonium compounds may have the same attributes.4

Used as a low-level disinfectant. High level of disinfection is achieved if different quats and alcohols are mixed.1 Mostly used in bathroom, floor, and general purpose cleaners.1

Bleach: 5.25 - 6.15% solution of sodium hypochlorite.2 Na-O-Cl

Oxidizers

Example: H2O2 Hydrogen peroxide Most commercial janitorial cleaners do not contain over 10% hydrogen peroxide. 4

Phenols/chlorinated phenols

HO

OBPC BP: 160-162 0C CI

Ortho benzyl para chlorophenol (OBPC) HO

Skin irritant. Occupational exposures may happen mostly through dermal contact.3 OPP BP: 286 0C

Ortho phenyl phenol (OPP) and p-tert-amylphenol. Examples :

+

Quaternary ammonium Compounds (quats)

H3C

N

Cl

CH3 H3C

Di-decyl di-methyl ammonium chloride CH3

R +

N

Cl

H2C

N Alkyl dimethyl benzyl ammonium chloride (benzalkonium chloride)

p-tert-amylphenol can be absorbed through the skin.

Quaternary ammonium compounds are salts that are soluble in water and alcohol.3

CH3

H3C

Other health effects

Purpose of use in cleaning products

Physicochemical properties

Hydrochloric acid H-Cl

32

Respiratory , skin, mucous membrane (eye) effects

Chemical formula

Because quats are not volatile, inhalation exposures can happen through products’ aerosolization.1 Commonly used solutions can cause nose and throat irritation. Benzalkonium chloride is a severe eye irritant.3 Limited evidence implicates quats in the development of allergic responses and occupational asthma.18,19 Exposures to benzalkonium chloride have been associated with combined respiratory and dermal hypersensitivity.20 Benzalkonium chloride is a primary skin irritant in solutions of less than 10%. Exposures to quats may cause allergic reactions to skin.20


Bleach dilutions clarified with household measurement terms

The Premier Safety Institute provided the CDC Guidelines with bleach dilutions using household measurement terms and equivalent parts per million (ppm) that can be used to translate recommendations for use in the patient care setting for environmental decontamination after cleaning, e.g., for Clostridium difficile. Below table presents the Premier Safety Institute’s expanded information that includes the bleach in dietary settings consistent with EPA regulations (21 CFR Part 178).2 Bleach solution

Dilution exact

Chlorine (ppm)

Dilution approximate

Household (ppm) approximate

Application

5.25% - 6.15%

Concentrate

52,500 - 61,500

Concentrate

52,500 - 61,500

*Patient Care

5.25% - 6.15%

1:10

5,250 - 6,150

1.5 cups/ 1 gallon

~6000

*Patient Care

5.25% - 6.15%

1:100

525-615

0.25 cup/ 1 gallon

~600

*Patient Care

5.25%

1:200

263

1 tablespoon/ 1 gallon